Association of serum inflammatory markers and diabetic retinopathy: a review of literature

OBJECTIVE

Diabetic retinopathy is the leading cause of irreversible blindness in the western world, among the working-age people. Its exact pathogenesis, however, remains obscure. Systemic inflammation is regarded to play a significant role in diabetes by contributing, among others, to the development of diabetic retinopathy. This review focuses on the possible involvement of the systemic inflammatory markers in the pathogenesis of diabetic retinopathy.

PATIENTS AND METHODS

We performed a systematic search of the literature of published papers until August 2017 using the PubMed search engine.

RESULTS

We demonstrated that many systemic inflammatory markers contribute to the pathogenesis and progression of retinopathy, while we highlighted in several occasions their usefulness as a key tool in the monitoring of the disease progression and the treatment efficacy.

CONCLUSIONS

To the best of our knowledge this is the first review in the literature that elaborates the possible association of serum inflammatory markers and diabetic retinopathy, a disease that may cause irreversible loss of vision.

Targeting histone deacetylases in endometrial cancer: a paradigm-shifting therapeutic strategy?

OBJECTIVE

Endometrial cancer is increasingly prevalent in western societies and affects mainly postmenopausal women; notably incidence rates have been rising by 1.9% per year on average since 2005. Although the early-stage endometrial cancer can be effectively managed with surgery, more advanced stages of the disease require multimodality treatment with varying results. In recent years, endometrial cancer has been extensively studied at the molecular level in an attempt to develop effective therapies. Recently, a family of compounds that alter epigenetic expression, namely histone deacetylase inhibitors, have shown promise as possible therapeutic agents in endometrial cancer. The present review aims to discuss the therapeutic potential of these agents.

MATERIALS AND METHODS

This literature review was performed using the MEDLINE database; the search terms histone, deacetylase, inhibitors, endometrial, targeted therapies for endometrial cancer were employed to identify relevant studies. We only reviewed English language publications and also considered studies that were not entirely focused on endometrial cancer. Ultimately, sixty-four articles published until January 2018 were incorporated into our review.

RESULTS

Studies in cell cultures have demonstrated that histone deacetylase inhibitors exert their antineoplastic activity by promoting expression of p21WAF1 and p27KIP1, cyclin-dependent kinase inhibitors, that have important roles in cell cycle regulation; importantly, the transcription of specific genes (e.g., E-cadherin, PTEN) that are commonly silenced in endometrial cancer is also enhanced. In addition to these abstracts effects, novel compounds with histone deacetylase inhibitor activity (e.g., scriptaid, trichostatin, entinostat) have also demonstrated significant antineoplastic activity both in vitro and in vivo, by liming tumor growth, inducing apoptosis, inhibiting angiogenesis and potentiating the effects of chemotherapy.

CONCLUSIONS

The applications of histone deacetylase inhibitors in endometrial cancer appear promising; nonetheless, additional trials are necessary to establish the therapeutic role, clinical utility, and safety of these promising compounds.

Intensive care unit outcomes following orthotopic liver transplantation: single-center experience and review of the literature

BACKGROUND/AIM

Orthotopic Liver Transplantation (OLT) is the treatment of choice for patients with end stage liver disease, acute liver failure, hepatocellular carcinoma and metabolic disorders. As a result of improvement in surgical and anesthesiological skills, advanced understanding of transplant immunology and better critical care management of complications, patients survive longer after liver transplantation. It has been gradually achieved one-year survival rates of 80-90%. During the early post-operative period, all patients undergoing OLT are admitted to the intensive care unit, as they need a management of both preexisting patient's conditions and post-operative complications, usually due to either adverse intra-operative or post-operative events. The purpose of this review is the detailed recording, understanding and interpretation of immediate post-operative complications occurred in patients undergoing OLT, in intensive care unit. This could help to improve patient's treatment and reduce the incidence of complications, with further reduction of morbidity-mortality and cost. We also present our experience from the first 32 OLT patients from Liver Transplantation Unit of Laiko General Hospital, the only Liver Transplantation Unit in Athens.

MATERIALS AND METHODS

This literature review was performed using the MEDLINE database. The key words were; Orthotopic liver transplantation; intensive care unit; post-operative complications; outcomes. One hundred-sixteen articles published in English until 2018 were used. We also use all the results from our 32 patients from our Liver Transplantation Unit during the period 07/2006 to 07/2009.

RESULTS

All patients undergoing OLT admitted to the intensive care unit for a period of time, depending on the occurrence of post-operative complications. The incidence of primary failure ranges between 2-14%, whereas post-operative bleeding ranges between 7-15%. The treatment is usually conservative, although surgical repair may need in 10-15%. Acute renal failure post-operative is not an infrequent problem too, and has been reported to occur in 9% to 78% of cases. Acute rejection normally occurs 7-14 days after OLT. Additionally, the delay of the weaning from mechanical ventilation in the immediate post-operative period could increase the complications. Infectious complications are quite common almost from the first post-operative day in intensive care unit.

CONCLUSIONS

Prolonged intensive care stay could increase the complications post-operative Infectious complications, renal and respiratory impairment are among the most common causes of early post-transplant morbidity and mortality.

The anti-inflammatory effects of exercise training promote atherosclerotic plaque stabilization in apolipoprotein E knockout mice with diabetic atherosclerosis

Physical exercise is the cornerstone of cardiovascular disease treatment. The present study investigated whether exercise training affects atherosclerotic plaque composition through the modification of inflammatoryrelated pathways in apolipoprotein E knockout (apoE^−/−) mice with diabetic atherosclerosis. Forty-five male apoE^−/− mice were randomized into three equivalent (n=15) groups: control (CO), sedentary (SED), and exercise (EX). Diabetes was induced by streptozotocin administration. High-fat diet was administered to all groups for 12 weeks. Afterwards, CO mice were euthanatized, while the sedentary and exercise groups continued high-fat diet for 6 additional weeks. Exercising mice followed an exercise program on motorizedtreadmill (5 times/week, 60 min/session). Then, blood samples and atherosclerotic plaques in the aortic root were examined. A considerable (P<0.001) regression of the atherosclerotic lesions was observed in the exercise group (180.339±75.613×10³µm²) compared to the control (325.485±72.302×10³ µm²) and sedentary (340.188±159.108×10³µm²) groups. We found decreased macrophages, matrix metalloproteinase-2 (MMP-2), MMP-3, MMP-8 and interleukin-6 (IL-6) concentrations (P<0.05) in the atherosclerotic plaques of the exercise group. Compared to both control and sedentary groups, exercise training significantly increased collagen (P<0.05), elastin (P<0.001), and tissue inhibitor of matrix metalloproteinase-2 (TIMP-2) (P<0.001) content in the atherosclerotic plaques. Those effects paralleled with increased fibrous cap thickness and less internal elastic lamina ruptures after exercise training (P<0.05), while body-weight and lipid parameters did not significantly change. Plasma MMP-2 and MMP-3 concentrations in atherosclerotic tissues followed a similar trend. From our study we can conclude that exercise training reduces and stabilizes atherosclerotic lesions in apoE^−/− mice with diabetic atherosclerosis. A favorable modification of the inflammatory regulators seems to explain those beneficial effects.

The differential anti-inflammatory effects of exercise modalities and their association with early carotid atherosclerosis progression in patients with type 2 diabetes

OBJECTIVE

Adipokines, visfatin, apelin, vaspin and ghrelin have emerged as novel cardiovascular risk factors. We aimed to evaluate the effects of different exercise modalities on the aforementioned novel adipokines and carotid intima-media thickness in patients with Type 2 diabetes mellitus.

METHODS

One hundred patients with Type 2 diabetes were equivalently (n = 25) randomized into four groups: (1) a control group with patients encouraged to perform self-controlled exercise; (2) a supervised aerobic exercise group (exercise four times/week, 60 min/session, 60-75% of maximum heart rate); (3) a resistance training group (60-80% baseline maximum load achieved in one repetition); and (4) a combined aerobic exercise plus resistance training group, as in groups 2 and 3. All participants had HbA(1c) levels ≥ 48 mmol/mol (≥ 6.5%), without overt diabetic vascular complications. Blood samples, clinical characteristics, peak oxygen uptake and carotid intima-media thickness measurements were obtained at baseline and at the end of the study, after 6 months.

RESULTS

At baseline, there were non-significant differences between groups. All active groups significantly ameliorated glycaemic profile, insulin sensitivity and triglycerides levels compared with the control group (P < 0.05). Aerobic training further improved lipids, systolic blood pressure and exercise capacity compared with the resistance training and the control groups (P < 0.05). Moreover, high-sensitivity C-reactive protein and visfatin decreased, while vaspin and apelin circulating levels increased within the aerobic exercise group and the aerobic exercise plus resistance training group, and compared with the other groups (P < 0.05). Within- and between-group comparisons showed negligible alterations in ghrelin serum levels and body weight after all exercise modalities. Finally, aerobic training attenuated the carotid intima-media thickness progression (0.017 ± 0.006 mm) compared with the control subjects (0.129 ± 0.042 mm, P < 0.001). That effect was independently associated with visfatin and amelioration of peak oxygen uptake.

CONCLUSIONS

In subjects with Type 2 diabetes, all exercise training modalities improved metabolic profile. Importantly, aerobic training predominantly ameliorated adipokines concentrations and carotid intima-media thickness progression.

How can we treat a patient with liver cirrhosis (hepatitis C virus), hepatocellular carcinoma, and synchronous colon cancer?

INTRODUCTION

The coexistence of liver cirrhosis with hepatocellular carcinoma (HCC) and colon cancer (Ca), which is a rare clinical condition, was treated in a liver transplant recipient.

PATIENTS AND METHODS

A 46-year-old man, diagnosed incidentally during an ultrasound (US) examination with a 3.5-cm HCC in segment VII related to chronic hepatitis C virus (HCV), was referred for liver resection. He underwent a laparoscopic protocol evaluation for liver cirrhosis. Liver appearance and biopsy of the left lobe showed Child B/C liver cirrhosis. Because he fulfilled the Milan criteria, we suggested an orthotopic liver transplantation (OLT). During protocol colonoscopy, we discovered an ulcerative sigmoid colon Ca. Three weeks after completing the pre-OLT assessment he underwent an OLT and was discharged home on day 9 on an immunosuppressive regimen of Everolimus, Myfortic, and Prezolone. Two months after transplantation, the patient underwent a sigmoidectomy and for nearly 1 month thereafter received chemotherapy for colon Ca (6 cycles of FOLFOX:Folinic Acid+Fluorouracil+Oxaliplatin). One and a half years after OLT, patient was in good condition but presented with an increased alpha fetoprotein (a-FP) without other findings. A couple of months later we discovered a colon Ca recurrence and 3 small liver metastases. Patient underwent a bowel resection with Hartmann's procedure. Almost immediately after the last operation, he was found to suffer multiple myeloma. He underwent chemotherapy for both malignancies with good responses, but a few months later died of severe sepsis.

DISCUSSION

The relevant literature regarding treatment of liver cirrhosis complicated with HCC and synchronous colon Ca reveals poor and controversial outcomes. Our patient underwent chemotherapy immediately after colon resection in the presence of with a good functioning liver. Although his condition was satisfactory after OLT, the optimal treatment of such complicated patients is as yet uncertain.

Glottic and supraglottic laryngeal cancer: epidemiology, treatment patterns and survival in 164 patients

PURPOSE

To evaluate the effectiveness of different therapeutic managements in relation to clinical disease stage, the location of the lesion and to register the rate of disease recurrence of patients with glottic and supraglottic laryngeal cancer, and to also study some specific epidemiologic characteristics.

METHODS

A series of 164 patients with laryngeal glottic and supraglottic squamous cell cancer (SCC) treated surgically, with radiation therapy (RT), chemotherapy or combination of these was analysed. After treatment, all patients were followed up for an average of 58 months. All data concerning the primary lesion, therapeutic management, recurrence, staging, 5-year overall survival and epidemiological characteristics such as smoking and alcohol abuse were recorded and analysed in combination with the follow up data.

RESULTS

The therapeutic approach most commonly used was RT for stage I tumors and surgery for stages II, III and IV. Stage I and II patients treated with RT had high recurrence rate (60%). Patients with recurrence had 45.3% 5-year overall survival rate and average survival time 80 months, whereas patients with no recurrence had 77.4% 5-year overall survival rate and average survival time 173 months (p=0.0001). There was significant difference in survival between stage I and III (p=0.035), stage I and IV (p=0.0038) and stage II and IV (0.0156). The average overall survival time for non smokers was 195 months (median 1707rpar;, while for smokers it was 99 months (median 100; p=0.0047). The average overall survival time for alcohol abusers was 79 months (median 54), while for those who did not use alcohol it was 153 months (median 150; p=0.016).

CONCLUSION

The 5-year overall survival rate was 61.3%. RT alone in stages I and II proved inferior in decreasing re-currences compared with surgery. Smokers had significantly shorter overall survival.

Expression of Smad4, E-cadherin and beta-catenin in advanced colorectal cancer: a retrospective study

PURPOSE

To correlate the expression of E-cadherin and beta-catenin with alterations of expression of Smad4 in advanced colorectal cancer (CRC).

METHODS

Tissue specimens from 75 colorectal cancer cases (Dukes stage C and D) were tested for Smad4, E-cadherin and beta-catenin by the Avidin-Biotin immunoperoxidase method. The results were correlated with patients' clinicopathological parameters.

RESULTS

Smad4 expression was lost or reduced in roughly 1 out of every 3 Dukes C and D CRCs. Association of Smad4 expression with other clinicopathological parameters was not noted. Association of expression of E-cadherin with other clinicopathological parameters was not noted, apart from tumor location. Expression of beta-catenin was not associated with clinicopathological parameters. Lack of expression of Smad4 was associated with lack of expression of both E-cadherin (<0.000) and beta-catenin (p<0.000). As regards the relation between E-cadherin and beta-catenin, the expression of each seemed to parallel the expression of the other (p<0.000). Beta-catenin was overexpressed in 68.5% of the specimens studied.

CONCLUSION

Clinically advanced CRC is associated with a reduced or complete lack of expression of Smad4. Ecadherin and beta-catenin are expressed in parallel with each other and also with Smad4. This tumor suppressor role of Smad4 by affecting both E-cadherin and beta-catenin may indicate a novel pathway for metastatic tumor via cellular reshaping. The precise underlined mechanism(s) and the clinical significance of these findings remain to be determined.

Long-term post transplant alloantibody monitoring: a single center experience

Between 2000 and 2010, 4241 sera from 597 renal transplant (RTx) recipients were monitored for DSA development. The patients were selected in the absence of immunological memory to donor HLA before RTx and were divided into two groups: the historic group, consisting of patients transplanted before December 1996 and the study group, consisting of those transplanted after December 1996. Ninety-two out of 597 (15.4%) patients developed de novo DSA post-RTx, while 196 had third party anti-HLA antibodies. DSA were more frequent in the historic group compared with the study group (P < 0.001). Anti-HLA class-III DSA predominated in both groups (84.6% vs. 69.7%) and were directed preferentially against donor HLA-DQ (65/92,70.6%). Recipients of class II-incompatible grafts developed DSA more frequently than those receiving class II-compatible grafts (P = 0.003). DSA production was not different between pre-sensitized and non-sensitized patients (P = 0.842). DSA class I (HR = 31.78), DSA class II (HR = 20.92), and non-DSA (HR = 5.94) were the only independent predictors for graft failure. In conclusion, this study shows the results of long-term post-transplant alloantibody monitoring, and confirm the strong association of DSA and graft loss. Protocols that remove anti-HLA antibodies from RTx recipients may benefit allograft survival.

Prognostic significance of p53 and Ki67 proteins expression in Greek gastric cancer patients

AIM

The variability of prognosis of gastric cancer (GC) within a pathological stage necessitates the identification of subgroups of patients with a more aggressive disease. The role of p53 and Ki67 expression in gastric carcinoma is far from being fully established. The aim of the present study was to evaluate the expression of p53 and Ki67 in gastric cancer and correlate the findings with several clinicopathological features and prognosis.

MATERIALS AND METHODS

Tissue samples from 93 patients treated by gastric resection for gastric carcinoma between 1996 and 2001 were used. Formalin-fixed paraffin-embedded tumors were studied by immunohistochemistry, using monoclonal antibodies to p53 and Ki67. The results were correlated with clinicopathological features and survival.

RESULTS

Stronger expression of p53 was related with tumor size greater than 5 cm and advanced stage. Stronger expression of Ki67 correlated with higher ratio of the number of metastatic lymph nodes to the total number of dissected lymph nodes (metastatic lymph node [MLN] ratio) and advanced stage. Moreover, p53 and Ki67 overexpression, tumor size greater than 5 cm, MLN ratio, depth of invasion, lymph node metastasis, stage III and IV and infiltrative macroscopic appearance were adverse prognostic factors. The levels of p53 and Ki67, the MLN ratio, the tumor size (above 5 cm) and the stage of the disease were identified as independent prognostic factors of survival.

CONCLUSIONS

In gastric cancer, the expression of p53 and Ki67 provides significant information about prognosis. The routine evaluation of p53 and Ki67 levels could be a useful tool in identification of patient with more aggressive disease and contribute to a better therapeutic approach.

Vascular complications in renal transplantation: a single-center experience in 1367 renal transplantations and review of the literature

Renal transplantation is the treatment of choice for end-stage renal disease. Vascular complications in renal transplantation are not uncommon and may often lead to allograft loss. The most common vascular complications are transplant renal artery stenosis, transplant renal artery thrombosis, transplant renal vein thrombosis, biopsy-induced vascular injuries, pseudoaneurysm formation, and hematomas. Transplant renal artery and vein thrombosis have an early onset and a dramatic clinical manifestation and usually lead to allograft loss. In contrast, transplant renal artery stenosis has better treatment possibilities, whereas the rest do not occur so often. In our institution, 1367 renal transplantations were performed from September 1980 to April 2005. During this period, we encountered 38 major vascular complications leading to graft loss and 19 transplant renal artery stenoses with successful treatment in the majority of cases. According to these data, we can conclude that renal transplantation is a safe therapeutic procedure for renal failure.

Kidney transplantation in lupus patients: a case-control study from a single centre

This study was conducted to determine kidney transplantation (KTx) outcomes for Greek patients with renal failure caused by lupus nephritis (LN) compared with matched controls, kidney recipients with other causes of end-stage renal disease (ESRD). Twenty-six patients with systemic lupus erythematosus (SLE) subjected to 26 kidney transplants were studied. For comparative purposes a case-control group was selected, matched for gender, source of donor, age and time of KTx. Patient and graft survival estimates were calculated with the Kaplan-Meier product limit estimator and survival estimates were compared with the log-rank test. All patients received cyclosporine or tacrolimus in combination with azathioprine or mycophenolate mofetil for chronic immunosuppression in addition to steroids. Fourteen transplants were from living-related donors and 12 were from deceased donors. The graft survival rates for lupus patients were 88% at 1 year, 67% at 5 years, 38% at 10 years, poorer than the control survival rates of 92%, 92% and 84% (P=0.004). Patient survival in the lupus group did not differ from that of the controls. Survival in the lupus group was 92% at 1 year, 77% at 5 years and 77% at 10 years vs. 96%, 92% and 92% (P=0.26). Chronic allograft nephropathy was the major cause of graft loss. Recurrent LN was detected in two patients, but only one lead to graft failure. SLE patients compared with controls had significantly higher rates of hypertension, cardiovascular disease, infections and malignancies. Compared with matched controls, SLE patients had inferior but still satisfactory graft survival rates, whereas patient survival rates were similar.

Urological complications: analysis and management of 1525 consecutive renal transplantations

Urological complications after renal transplantation increase morbidity, delay graft function, and occasionally lead to graft and/or patient loss. The aim of this study was to analyze the causes of and therapeutic approaches to urological complications in renal transplantation as they related to patient outcomes. A series of 1525 consecutive renal transplantations were performed over a 24-year period. Renal grafts were obtained in 814 cases from living-related and in 711 from cadaveric donors. A Lich-Gregoire ureterovesical reimplantation technique with minimal bladder wall dissection was employed in all cases. Ureteral stents were routinely used in cadaveric transplants and exceptionally among living-related grafts. Urological complications were classified according to the mechanism and site of urinary tract involvement: graft ureteropelvic junction obstruction/stenosis (A), ureteral obstruction/stenosis (B), ureterovesical anastomosis obstruction/stenosis (C), urinary leakage (D), and other (E). Overall, we encountered 96 urological complications (6.3%). Group C complications occurred in 29 cases (30.2%), followed by 27 cases (28.1%) for group B patients, 25 cases (26.0%) for group D, 12 cases (12.5%) for group A, and 3 cases (3.1%) for group E patients. Surgical intervention was required in 49 (51.0%) of all urological complications. The others (n = 47, 49.0%) were treated either conservatively or by minimally invasive procedures. A rapid diagnosis of urological complications, assisted by early posttransplant DTPA scans, routine ultrasonography, and especially prompt treatment, resulted in compensation of renal graft dysfunction in the vast majority (n = 90, 93.8%) of cases. Surgical techniques of graft retrieval and reimplantation are of utmost importance to minimize the incidence of urological complications.

Brown tumor of the fibula: unusual presentation of an uncommon manifestation. Report of a case and review of the literature

Brown tumors are erosive bony lesions caused by rapid osteoclastic activity and peritrabecular fibrosis due to hyperparathyroidism, resulting in a local destructive phenomenon. Although brown tumors are the most pathognomonic sign of hyperparathyroidism, they are very rarely observed at present as a result of early detection of hypercalcemia and elevated parathyroid hormone levels. The rare appearance of this entity in everyday practice is troublesome for both patients and physicians, because whenever it emerges, diagnosis could be mistaken for a giant cell tumor of the bone. However, clinical, biochemical, and radiologic findings can easily guide the diagnosis if one considers the full continuum of findings and their association with subject's medical history, instead of focusing only on bone lesion. In this report we present a case of brown tumor in the fibula with a short literature review, whose aggressive presentation and unawareness of the skeletal findings of hyperparathyroidism puzzled the caring doctors. This case illustrates the need for continuous vigilance of any physician, regardless of his specialty or his position in medical services structures.

New concepts in the therapeutic options of liver metastases from colorectal cancer

Colorectal cancer is one of the most frequent malignant neoplasms causing approximately 10% of cancer deaths. Up to 30% of patients with primary colorectal cancer have already liver metastatic disease at the time of diagnosis. Untreated patients with liver metastases share a poor prognosis with an average survival of 12 months. In contrast, patients whose metastatic lesions are surgically treated have an average 5-year survival rate of 40%. Only 10-15% of initial colorectal liver metastases are considered as being resectable. In the remaining patients, the current trend is to downstage initially unresectable metastases by neoadjuvant therapy (systemic or regional chemotherapy, portal vein embolization - PVE - or hepatic artery chemoembolization), tumor ablation and two-stage hepatectomy, alone or in combinations. This study reviews the current therapeutic options for colorectal liver metastases and their contribution to improve survival rates.

Substantial Increase in Cadaveric Organ Transplantation in Greece for the Period 2001–2005

The Hellenic Transplant Organization (HTO), a nonprofit organization sector of the Greek Ministry of Health, was officially established in 1999. Since March 2001, HTO has been responsible for donation and transplantation processes in Greece and organ sharing between Greece and other European countries. The organization's main tasks are: donor referral, charting, donor assessment, organ evaluation, organ allocation and transplantation. Today, the results show increased success rates to previously believed unthinkable levels. Precisely, the percentage of referred versus used cadaveric donors increased by 468% and 134%, respectively. Cadaveric kidney transplantation has also shown remarkable progress with a 126% increase during the same period. Similarly, liver transplantation showed a threefold rise (89%) during the same time. Unfortunately, heart and lung transplantations remain low, thus preventing statistical conclusions to be drawn. Although Greece in previous years had the lowest donor and transplantation rates per million population, its position compared with other European countries is expected to rise significantly this year. Undoubtedly, the numbers and percentages compared to previous years are due to the radical changes implemented by the HTO, by introducing transplant coordination principles and procurement management, which were concepts not previously established in Greece. However, there are still major obstacles, such as intensivists' refusal to disconnect, inaccessible geographical locations, few transplant centers, and society's suspicion of organ donation concept, that still need attention. Nevertheless, the first step has been taken and other European countries standards will hopefully be attained soon.

Improving the Organ Transplantation Program in Greece: Institution of Local Transplant Coordinators’ Network

The success of a transplantation program depends upon the quality and effectiveness of the donation process, whereby the key role is assigned to the local transplant coordinator (TxC). This important professional figure was only recently established in Greece. The local TxC duties were outlined alongside those of the Hellenic Transplant Organization (HTO) foundation in 1999, whereby three different transplant coordinator positions--central, local, and clinical--were specified. In 2002, the above-mentioned positions were legally consolidated. Local TxCs had to be doctors or nurses, in a 70%-30% ratio, already working in intensive care unit (ICU) and had to be appointed by the hospital and ICU directors in each hospital as requested by the HTO. By the end of 2004, this network consisted of 122 TxCs located in 74 ICUs, especially trained in donation procedures and ethics. Half of the doctors were ICU directors, especially appointed to influence ICU personnel. Furthermore in 2005, the board of directors of HTO decided that there should be closer cooperation between the 45 most donor generating ICUs and their TxCs. It was decided that the local TxCs would work part-time and receive a monthly grant. The 45 ICU network started in 2005, resulting in an 154% increased rate of potential donor referrals and a 33% and almost 38% increase in actual donors and transplantations, respectively, compared to 2004. This substantial increase was achieved by the institution of TxC network.

Transorbital sonographic monitoring of optic nerve diameter in patients with severe brain injury

OBJECTIVE

We investigated whether alterations in the optic nerve diameter (OND) correlated with brain computed tomography (CT) imaging results among patients with brain injury and whether monitoring of OND could predict brain death.

PATIENTS AND METHODS

We enrolled 54 patients with brain injury (Glasgow Coma Scale < 8) and 53 controls. OND measurements were performed 3 mm posterior to the papillae by means of transorbital sonography. The severity of the injury was classified according to a semiquantitative CT neuroimaging scale (1 to 4). All patients underwent 3 repeated evaluations of OND combined with synchronous CT scans.

RESULTS

Twenty-two patients progressed to brain death, while 32 patients showed gradual clinical improvement. Upon admission, the patients showed significantly increased OND (4.84 +/- 1.2 mm) compared with the controls (3.49 +/- 1.1 mm; P < .001). The median intraobserver variation of OND was 0.2 mm (95% confidence intervals [CI]: 0.1-0.7). The median interobserver variation of OND was 0.3 mm (95% CI: 0.1-0.9). Alterations in the OND were significantly correlated with the neuroimaging scale on 3 repeated evaluations: r = .65, r = .70, and r = .73 (all P < .001). An OND greater than 5.9 mm (specificity = 65% and sensitivity = 74%; P < .01) and a 2.5 mm increased OND between repeated measurements (specificity = 70% and sensitivity = 81%; P < .01) were associated with a poor prognosis.

CONCLUSIONS

Alterations in OND strongly correlated with neuroimaging results among patients with brain injury. However, monitoring of OND exhibited a low predictive value for brain death.

The coexistence of carcinoma of the rectum and of ischiorectal abscess: what is the optimal therapeutic approach?

This article deals with the dilemma of the surgeon to choose the optimal surgical procedure in case of coexistence of ischiorectal abscess and a rectal carcinoma. The case of a patient suffering from ischiorectal abscess in association with rectal carcinoma is reported.

Diabetic muscle infarction after kidney and pancreas transplantation: case report and literature review

Diabetic muscle infarction (DMI) is a rare, long-term complication of poorly controlled diabetes (typically of type I). DMI was first described in 1965 and more than 100 cases have been reported thereafter in the English literature. Usually, there is a coexistence with concomitant nephropathy, neuropathy, and retinopathy. The etiology remains uncertain, but appears to be attributable to diabetic microangiopathy and hypercoagulability and is believed that hypoxia-reperfusion injury is involved. DMI presents with sudden onset of pain associated with a tender mass in the thigh in most instances. The diagnosis is based on magnetic resonance imaging, which is not specific but highly indicative. Treatment is conservative with relapses occurring in 50% of the patients, but not necessarily in the same muscle group. We describe a case of DMI that occurred 4 months after simultaneous kidney and pancreas transplantation in one patient with type I diabetes mellitus and end-stage renal disease.

The role of ThinPrep cytology in the investigation of lung tumors

AIMS OF THE STUDY

The aim of this study was to evaluate the role of liquid-based cytology with the ThinPrep (TP) (Cytyc; Cytyc, Co, Boxborough, MA, USA) technique, using fine-needle aspiration (FNA) for sampling, in the investigation of suspicious pulmonary lesions.

METHODS

We performed percutaneous computed tomography (CT)-guided FNA biopsy of focal pulmonary lesions in 80 adult patients. Study subjects were all consecutive patients and potential candidates for surgery. The sample was then examined by both conventional smears (CS) and TP techniques. TP smears of all FNA were prepared from needle rinsing obtained following preparation of CS. All cytological diagnoses were correlated with the CS and/or thoracotomy histological diagnoses in order to evaluate the role of liquid-based cytology with the TP technique.

RESULTS

Using TP technique diagnosis was successfully established in 75 patients out of 80, whereas using CS cytology diagnosis was established in 54 patients (p<0.001, z=3899). Inadequate material was observed in 5 cases (6.25%) with the TP technique and in 13 cases (16.25%) with the CS technique (z=-2.77, p<0.05).

CONCLUSIONS

We believe that the TP technique has a good overall yield for the diagnosis of suspicious for malignant lung lesions. We found that the accuracy of determining lung cancer was excellent.

Coexistence of primary adrenal hydatid cyst and arterial hypertension: report of a case and review of the literature

Adrenal gland has been considered as an atypical localization of Echinococcus Granulosus and the reported incidence is 0.5%. We report a rare case of coexistence of primary adrenal hydatid cyst and arterial hypertension. The patient underwent surgical excision of the adrenal gland with a slight improvement of blood pressure's regulation, requiring antihypertensive medication postoperatively. Till today, two cases of coexistence of primary adrenal hydatid cyst and arterial hypertension have been reported in the literature. However there is not clear and acceptable explanation about the relation and the involved pathogenetic mechanism. Resection of the cyst with conservation of the gland remains the optimal procedure. In case of haemorrhage or failure to perform a cystectomy, ablation of the entire adrenal gland including the cyst should be performed.

Pancreatic abscess due to perforation of duodenal diverticulum

Duodenal diverticula are usually incidental findings, but some times could be complicated with inflammatory or pressures effects to pancreas tissue. We present a rare case of pancreatic abscess caused by a perforated diverticulum, arising from the distal end of the second part of the duodenum.

Comparison between transcranial color Doppler ultrasonography and angiography in the confirmation of brain death

OBJECTIVE

Cerebral blood flow tests have increasingly been advocated for the confirmation of brain death (BD). Angiography has been considered the gold standard in the diagnosis of BD but is invasive. We validated transcranial color Doppler ultrasonography (TCD) to confirm BD by comparing it to angiography.

PATIENTS AND METHODS

Forty patients experienced the clinical diagnosis of brain death due to head injury in 19 cases (47.5%), cerebral hemorrhage in 11 (27.5%), subarachnoid hemorrhage in 7 (17.5%), and cerebral infarction in 3 (7.5%). Blood pressure, heart rate, SPO2, and PCO2 were monitored throughout the study. Patients were excluded if episodes of hypoxia, arrhythmia, and hypotension occurred during examinations, or if the TCD was not technically feasible.

RESULTS

Both angiography and TCD confirmed BD in all patients. The agreement between the above methods to confirm BD was 100%. Angiography showed the absence of filling of intracranial arteries, while TCD revealed: (1) brief systolic forward flow or systolic spikes and diastolic reversed flow (50%); (2) brief systolic forward flow or systolic spikes and no diastolic flow (25%); (3) no demonstrable flow in a patient in whom flow had been clearly documented on a previous TCD examination (12.5%). Five patients required repeated TCD examinations, because of initial detection of a diastolic to-and-fro flow pattern. BD was confirmed by TCD in the above patients after 30 hours of clinical BD.

CONCLUSION

TCD was a sensitive tool to diagnose BD, affording a reliable alternative examination to standard angiography.

Changes of CPK and CPK-MB levels after open and laparoscopic cholecystectomy

According to the World Health Organization, an increased ratio (more than 6%) of CPK-MB to total CPK may indicate the diagnosis of an acute infarction. But false elevation of CPK and CPK-MB levels after noncardiac operation, because of soft tissue damage, may confuse the clinicians in detecting myocardial infarction in early postoperative period. In order to determine the usefulness of CPK-MB to total CPK ratio in detecting myocardial infarction after open and laparoscopic cholecystectomy, we measured the serum levels of these markers in 135 patients, immediately after the operation and for the next five days. Patients were divided into four groups according to type of surgical procedure, as follows: Group I: a right oblique subcostal (Kocher's) incision was performed in 29 patients, Group II: a right paramedian transrectal incision was performed in 52 patients, Group III: a vertical high midline incision was performed in 17 patients, Group IV: laparoscopic cholecystectomy was performed in 37 patients. Although we found increased levels of CPK and CPK-MB after all the types of cholecystectomy, but in any case the CPK-MB exceeded more than 6% of total serum CPK. Furthermore we noticed that the patients who underwent open cholecystectomy with right oblique subcostal incision had the most elevated CPK and CPK-MB levels comparing to the other types of cholecystectomy. In conclusion, tissue damage after elective cholecystectomy is minimal and CPK-MB to total CPK ratio is a secure marker in detection of myocardial infarction during early post-operation period, after cholecystectomy.

Acute mesenteric ischaemia, a highly lethal disease with a devastating outcome

Background: Acute mesenteric ischaemia remains a serious condition requiring emergency surgical management. The mortality rate still remains high, due to the unspecific and delayed diagnosis and ranges from 59% to 100%. Purpose of our study is to present our experience in the management of the disease. Patients and methods: This is a retrospective study of 61 patients treated surgically for acute mesenteric ischaemia, between 1988 and 2004. All patients underwent a laparotomy. 75% of the patients were operated within the first 24 hours and the rest within 48 hours. Results: Superior mesenteric artery embolism occurred in 36 (59%), thrombosis in 21 (34%) and superior mesenteric vein thrombosis in 4 (7%) cases. In 49 (80%) cases, embolectomy or thrombectomy of the superior mesenteric artery with resection of the necrotic segment of the bowel was performed. Twelve cases (20%) were considered inoperable because of massive bowel necrosis. According to our study mortality and morbidity rate amounts to 75% and 80% respectively. No significant difference in the mortality rate between patients with embolism (75%) and thrombosis (76%) was found. However a significant increase of mortality rate was observed when the surgical intervention became afterwards the first 24-hour period. (72% versus 87%). Patients who underwent embolectomy or thrombectomy with bowel resection presented an improved survival rate compared with patients that underwent only bowel resection. (p = 0.019) Conclusions: Acute mesenteric ischaemia has the characteristics of a highly lethal condition and only early recognition and appropriate treatment can reduce the potential for a devastating outcome. The reduction of time interval from the beginning of symptoms up to the treatment remains the main critical important factor.

Reconstructive surgery for kidney transplant recipients

Many decades have passed since the first kidney transplantation, which is now the most common organ transplant performed worldwide. Despite the impressive advances, some patients may develop posttransplant complications that require proper management and treatment. The plastic and reconstructive surgeon, among others, may be called on to help resolve a number of reconstructive problems present in the immunosuppressed kidney recipients. This study presents our experience with 41 kidney recipients who needed plastic surgical treatment. Patients were placed into one of three study groups according to the type of posttransplant surgical condition. Group 1 included 17 patients with posttraumatic wound healing problems; group 2, 17 patients with skin tumors; and group 3, 7 patients with other posttransplant surgical complications. Only two of these patients had early posttransplant wound dehiscence; the remaining patients suffered late complications. In conclusion, the kidney recipient can successfully undergo minor or major reconstructive procedures. The possibility of surgical problems arising during the early posttransplant period presents increased complication rates, possibly due to high immunosuppressive drug levels.

Endovascular repair as first-choice treatment of iliac pseudoaneurysms following renal transplantation

Pseudoaneurysms of the arterial anastomosis are rare complications of renal transplantation. We report three cases of patients with extrarenal pseudoaneurysms and describe their treatment by endovascular placement of covered stents. Two of these aneurysms were due to vascular infections by fungi. An 8-week antifungal therapy proved to be successful in preventing the risk of fungal infection of the graft material in both patients. All three of our grafts remained open 2 months to 3 years after their placement with no evidence of stenosis or infection.

Pretransplantation prevalence of human herpes virus 8 antibodies in kidney donors and recipients in Athens, Greece

AIM

The aim of this study was to estimate the prevalence of anti-human herpes virus 8 (HHV8) antibodies in a cohort of renal donors and recipients in Athens, Greece. HHV8, the etiological agent of posttransplantation Kaposi's sarcoma, causes significant morbidity and mortality.

METHODS

Serum samples from 97 subjects (49 donors and 48 recipients) were tested with an enzyme-linked immunosorbent assay (ELISA) prior to renal transplantation.

RESULTS

Only 2 subjects (both transplant recipients) were found to be anti-HHV8-positive. Both subjects were of Albanian origin.

CONCLUSION

Infection with HHV8 appears to be limited in the Greek population. However, in light of significant long-term morbidity with which HHV8 is related in immunocompromized patients, studies on the general population are needed to estimate the prevalence of HHV8 infection in the country and devise clear guidelines for pretransplantation screening and posttransplantation follow-up.

Delayed renal graft function: the influence of immunosuppression

INTRODUCTION

We evaluated the influence of different immunosuppressive regimens on delayed renal graft function and progression of renal function in the first year after transplantation.

PATIENTS AND METHODS

Patients were divided into four groups according to the immunosuppressive regimen received: (1) rapamycin (Rap) + mycophenolate mofetil (MMF) + methylprednisolone (MP) + daclizumab (Dmab); (n = 44); (2) tacrolimus (Tac) + MMF + MP + Dmab (n = 39); (3) cyclosporine (CsA) + MMF + MP + basiliximab (Bmab); (n = 30); (4) antithymocyte globulin (ATG) + MMF + MP and CsA after ATG withdrawal (n = 40). Data were analyzed using ANOVA and linear regression. Delayed graft function was defined as the need for hemodialysis posttransplantation.

RESULTS

There were no statistically significant differences between the four groups in terms of gender, time on dialysis before transplantation, histocompatibility, donor age, and cold ischemia time. However, age (49.8, 50.4, 49.8, and 43.5 years, P < .05), panel reactive antibodies (22%, 39%, 27%, 34%, P < .05) and time of delayed graft function (12, 7, 3, 6 days, P < .05) were significantly different between the four groups. The time of delayed graft function depended on the immunosuppressive regimen, as well as donor and recipient age (P < .05). The creatinine clearance demonstrated a statistically significant difference between the four groups in the first month after transplantation (45, 46, 61, 53 mL/min, P < .05), though no further difference was observed at the month 12th.

CONCLUSIONS

The type of immunosuppressive therapy seems to substantially influence the time of recovery from delayed renal graft function, even though it does not seem to affect future graft function. Especially Rap, probably due to its potent antiproliferative effects, seems to prolong the length of graft recovery after renal transplantation.

A comparative randomised study of valacyclovir vs. oral ganciclovir for cytomegalovirus prophylaxis in renal transplant recipients

An open, prospective, randomised study was conducted to compare the safety and efficacy of valacyclovir vs. oral ganciclovir for cytomegalovirus (CMV) prophylaxis in renal transplant recipients. Eighty-three renal transplant recipients were assigned randomly to receive valacyclovir (n=43) or oral ganciclovir (n=40) for the first 3 months after transplantation. Both groups were similar in terms of demographics, primary renal disease, graft source, HLA matching, immunosuppressive therapy and donor-recipient CMV antibody status. CMV infection was diagnosed by detection of virus DNA in plasma with the Amplicor CMV Test. CMV disease was observed in only one patient belonging to the ganciclovir group, who developed enterocolitis 6 months post-transplantation. No difference was observed between the two treatment groups with respect to detection of CMV DNA, virus infections other than CMV, acute rejection episodes, and serum creatinine levels at 3 and 6 months following transplantation. An increased number of bacterial infections was noted in the ganciclovir group (p 0.003). No adverse reactions with either treatment were reported. The estimated cost of valacyclovir treatment was 20% higher than that of ganciclovir treatment. Overall, both valacyclovir and oral ganciclovir were found to be effective and safe for CMV prophylaxis in renal transplant recipients. Decisions regarding prophylactic regimens should include additional criteria, such as cost or possible development of resistance.

Carotid body paraganglioma and SDHD mutation in a Greek family

BACKGROUND

Carotid body (CB) is a highly specialized paraganglion originating from the neural crest ectoderm. CB paraganglion can be caused either by a genetic predisposition (hereditary paraganglia) or by chronic hypoxic stimulation. Germline mutations in any of the following genes: SDHD, SDHC, SDHB, PGL2 or other unknown genes, can cause paragangliomas (PGLs).

MATERIALS AND METHODS

We studied a Greek family in which the two daughters had carotid body paraganglioma, whereas both parents did not. RNA extraction, reverse transcriptase polymerase chain reaction and direct DNA sequencing were performed, in order to identify SDHD mutations in all four exons.

RESULTS

Our results revealed the existence of the missense mutation Y114C, in exon-4 of the SDHD gene, in the unaffected father and both affected sisters.

CONCLUSION

DNA testing was performed, for the first time in Greece, on patients with carotid body tumor. This marks a new geographical location, in the literature, for this mutation.

Polyomavirus BK infection in Greek renal transplant recipients

BK polyoma virus associated nephropathy is increasingly recognized as an important cause of allograft dysfunction among renal transplant recipients. Herein we present the cases of two renal transplant recipients who developed progressive functional deterioration suspicious for BK polyoma virus involvement. One patient had been treated with mycophenolate mofetil (MMF), cyclosporine (CsA), and prednisolone (P), and the second patient with tacrolimus (Tac), MMF, and (P). Using quantitative real-time polymerase chain reactions for BK virus DNA, we monitored the content of BK virus in the blood to evaluate disease progression. The high BK virus load initially detected in the blood samples from these patients decreased in the patient who received MMF, CsA, and P after the reduction of immunosuppression, but not in the patient who was treated with Tac, MMF and P. In contrast to previous reports, our patients had not received treatment with anti-lymphocyte globulin (ALG) or monoclonal anti-CD3 antibody (OKT3) after transplantation. It is concluded that even in the absence of vigorous antirejection treatment, immunosuppressive therapy based on Tac and MMF may carry the risk of BK virus-associated nephropathy. Because BK virus specific antiviral therapy is not available, its course may be monitored by measuring the viral load in blood.

Early experience with cyclosporine: a historic perspective

Cyclosporine, a new antilymphocyte peptide, was tested in heterotopic heart transplantation between two different strains of rats. Prolongation of rat heart allograft survival was observed in treated hosts as compared with untreated controls (P<.001). These pioneering studies in pedicle animal grafts proved that cyclosporine is an extremely potent immunosuppressive drug. Its ability to suppress allograft rejection episodes could be applied to other species of animals and to humans.

Breast arterial calcifications as an indicator of systemic vascular disease

PURPOSE

To evaluate the association between mammographically detected arterial calcifications and systemic vascular disease.

MATERIAL AND METHODS

The medical records of 77 women who had either breast arterial calcifications or underwent surgery for carotid stenosis, abdominal aortic aneurysm, or femoropopliteal bypass (study groups A and B) were evaluated and compared with 33 women without breast arterial calcifications (group C). Patients in both arms of the study underwent additional vascular tests or mammography.

RESULTS

Currently available data indicate that there is a statistically significant correlation between the presence of arterial calcifications on the mammogram and atheromatosis of the carotid or femoral arteries.

CONCLUSION

Screening mammograms might be useful in the detection of women at risk for systemic vascular disease.

Cyclosporine levels at 2 hours after dose and body mass index in relation to graft function in renal transplant patients treated with azathioprine or mycophenolate mofetil

The aim of this study was to evaluate the effect of C(2) levels on renal graft function in relation to body mass index (BMI). This retrospective study of 95 renal transplant patients included 53 on AZA and 42 on MMF at 3.1 years after transplantation. The cohort was divided into groups according to their C(2) levels, namely <600 ng/mL, 600 to 900 ng/mL, or >900 ng/mL, and according to BMI (>26 kg/m(2)). In every group, we evaluated the percentage of patients with an increase in creatinine by 1 mg/dL or >/=50% from the first year posttransplant. There was no difference in age, gender, graft source, and dose of corticosteroids or CsA between the groups. Patients on AZA with C(2) 600 to 900 ng/mL showed a lower prevalence of renal dysfunction (3.4%) than those with C(2) levels <600 ng/mL (14.3%) or >900 ng/mL (20%). Seventeen percent of the patients on AZA and 11.9% on MMF had BMI >26 kg/m(2) (P = NS). An increased serum creatinine was present in 22.2% of patients with BMI >26 kg/m(2) in the AZA group vs 20% in the cohort MMF (P = NS). These findings suggest that long-standing renal recipients on AZA with C(2) levels of between 600 and 900 ng/mL show better preservation of renal function. We did not identify differences on the basis of C(2) levels in MMF-treated recipients. The influence of BMI on long-term graft function seemed to be independent of AZA or MMF therapy.

Metastatic melanoma within a transplanted kidney: a case report

A 57-year-old woman recipient of a cadaveric renal allograft displayed metastatic melanoma within the transplant. The patient, who received imunnosuppressive therapy with cyclosporine, azathioprine, and prednisone, displayed normal renal function for 10 months posttransplantation. She was admitted due to multiple, large, rapidly growing skin nodules over the lower abdomen and to dyspnea. After a diagnostic evaluation, the renal graft was removed, revealing metastatic melanoma within the transplanted kidney and 2 focal points of melanoma within the skin lesions. The patient returned to hemodialysis, received chemotherapy and interferon A, but failed to respond and died 11 days after the nephrectomy.

Prolonged ureteral stenting in obstruction after renal transplantation: long-term results

BACKGROUND

Renal transplantation is an effective treatment for end-stage renal disease. Ureteral stenosis is the most frequent urologic complication. We report our long-term follow-up results concerning endourologic treatment of ureteral obstruction after renal transplantation.

METHODS

Between May 1997 and September 2000, 15 patients with renal transplant obstructive uropathy were managed with percutaneous nephrostomy and prolonged ureteral stenting.

RESULTS

Percutaneous nephrostomies were performed successfully in all 15 kidneys. In 13 patients, antegrade ureteral stenting was attempted, which was successful in 11 patients (85%). After prolonged ureteral stenting (mean duration 15 months), the stent was removed in all patients, 90% of whom had no recurrence. During follow-up (36 to 71 months; mean 51), urea, creatinine, sodium, and potassium determinations and ultrasound scans were performed. Success was defined as a reduction in hydronephrosis. No major complications were observed.

CONCLUSIONS

Modern endourologic procedures have replaced open reconstructive surgery in most patients with ureteral obstruction after renal transplantation, because they may offer a definitive treatment with low morbidity.

Human herpesvirus type 8 genotypes in iatrogenic, classic and AIDS-associated Kaposi's sarcoma from Greece

BACKGROUND

Kaposi's sarcoma-associated herpesvirus (KSHV)/human herpesvirus 8 (HHV-8) is consistently found in almost all observed Kaposi's sarcomas (KS), whether AIDS-associated, iatrogenic or classic. To our knowledge no data are available on the genetic polymorphism of HHV-8 from Greece. We report the study of 15 renal transplant recipients with KS, 5 with AIDS-associated KS, 11 with classic KS and 60 healthy individuals from Greece.

MATERIALS AND METHODS

Polymerase chain reaction (PCR) was carried out on DNA extracted from peripheral-blood mononuclear cells (PBMC) or KS cutaneous biopsies, using specific primers for the HHV-8, KS330 fragment from ORF-26 (233 bp) and the highly variable region (VR1) from ORF-K1 (363 bp).

RESULTS

HHV-8 DNA was detected in 30 out of 31 (97%) KS cases, regardless of their clinico-pathological subtype and in 10 out of 60 (16.7%) healthy individuals. Sequencing of the ORF26 fragment demonstrated that the 40 HHV-8 strains were of the A and C sub-types. Furthermore, sequencing of the ORF-K1 showed that these HHV-8 strains of Greek origin were of the A1, A4, C1 or C3 sub-type.

CONCLUSION

Our findings imply a possible link of the C3 subtype of HHV-8 in renal transplant-related KS cases (iatrogenic KS) in Greece, a link of the A4 subtype in AIDS-associated KS cases and a potential involvement of the A1 subtype in Greek classic KS incidences, as HHV-8 strains among healthy individual tested belong to the C1, C3 or A1 subtypes.

Hemostatic function and carotid artery disease

AIM

Since conventional risk factors predict less than one half of future cardiovascular events, other factors that contribute to atherogenesis need to be evaluated. The aim of this study was to investigate whether clotting factors are associated with carotid artery disease. Furthermore, we tried to determine whether clotting factors could be used to predict the risk of cerebrovascular events in patients with internal carotid artery stenosis.

METHODS

Twenty-six patients with high-grade (>70%) internal carotid artery stenosis and 43 age-matched controls were evaluated for atherogenic risk factors and hemostatic function. Laboratory tests included plasma assays of fibrinogen, tissue plasminogen activator (TPA), D-dimer, plasminogen activator inhibitor 1 (PAI-1), plasminogen and factor VII:c. Nineteen (72%) patients had history of stroke or transient ischemic attack, while the remaining 7 (28%) were asymptomatic. Statistical analysis was performed using multiple linear regression analysis.

RESULTS

Carotid artery stenosis was associated with high levels of TPA (p<0.001), D-dimer (p=0.019) and PAI-1 (p<0.001). No statistically significant correlation was found between the presence of carotid artery disease and the levels of fibrinogen (p=0.28), plasminogen (p=0.96) or factor VII:c (p=0.19). As regards the clinical manifestations, none of the studied clotting factors was correlated with the history of cerebrovascular events in the patients with carotid stenosis.

CONCLUSION

The results of this study show that the hemostatic system may play a role in the development of carotid artery atherosclerotic disease, while it does not seem to affect the development of symptoms in patients with carotid stenosis.

Pre-operative Tc-99m-sestamibi scanning and intra-operative nuclear mapping: are they accurate in localizing parathyroid adenomas?

PURPOSE

Presentation of the results of Tc-99m-sestamibi imaging in the pre-operative localization of parathyroid adenomas and the intra-operative localization of those lesions using a gamma detector (prospective study).

PATIENTS & METHODS

Eighteen consecutive patients aged 27-75 years with primary hyperparathyroidism (PHPT) underwent Tc-99m-sestamibi scanning 1-2 hours before the operation and the presence of a single adenoma was recognized. All our patients underwent bilateral neck exploration based on pre-operative scanning and intra-operative gamma detector guidance and the adenoma was detected in the positions shown by both methods.

RESULTS

In 16 patients we found a single adenoma localized in the same position shown by pre-operative scanning, while the intra-operative method accurately revealed all abnormal glands. In one of the two patients where an inaccurate pre-operative localization technique had been carried out, we performed thyroid lobectomy (the adenoma proved to be intrathyroidal), while the other one had an adenoma which was not close to the site indicated by the pre-operative scintigraphy. Serum calcium reverted to normal within a few days postoperatively.

CONCLUSION

Patients with true-positive scans for single parathyroid adenoma could be eligible for minimally invasive operations since the abnormal gland is easily identified by the above-mentioned methods.

Study of "de novo" malignancies among greek renal transplant recipients

The incidence of malignancy was estimated in 1055 renal transplant recipients, engrafted between 1983 and 2001 including 611 grafts from living and 444 from cadaveric donors. The meoplasms were 22 skin cancers, 18 Kaposi's sarcomas, 10 lymphomas nine non-Hodgkin's and one Hodgkin's lymphoma) and 24 visceral carcinomas. Skin cancers were completely excised. Patients with Kaposi sarcoma were treated by tapering the immunosuppression with cessation of cyclosporine. In addition, four patients received chemotherapy, and one of them received local radiotherapy. All patients with lymphomas were treated by cessation of calcineurin inhibitors with modulation of the immunosuppression to levels that were safe for the graft. Furthermore, five patients underwent first line chemotherapy, two patients radiotherapy and two patients, surgical removal of the tumor. The patients with visceral tumors were treated surgically with excision of the lesions when possible, without severe modification of the immunosuppressive regimen. Chemotherapy or radiotherapy was added accordingly. Disease-related mortality rate in patients with skin cancer was 4.5%; in Kaposi's Sarcoma cases 11.11%; in lymphomas 50%; and in all the other instances, 45.8%. This study shows the increased incidence of certain malignancies in transplant recipients, illustrating the importance of cancer surveillance following kidney transplantation. A substantial reduction or even cessation of immunosuppressive therapy may be necessary to achieve patient survival.